THE February 2016 session of the ongoing trial of scientist Tim Noakes for his ‘unconventional’ views on butter, eggs, bacon and broccoli, was true to form. It was filled with twists, turns, drama and intrigue.

In the first of a two-part series, I look at the consequences of the Health Professions Council of SA (HPCSA) hearing against Noakes so far. I also look at why it has turned into an object lesson in unintended consequences for doctors and dietitians who don’t want Noakes giving dietary advice.

By Marika Sboros

The public calls the HPCSA hearing the “Banting for Babies Trial”, even the “Nutrition Trial of the Century”. There’s good reason for that. And if the HPCSA hoped it would silence Noakes, it has done the opposite.

The hearing has given him a global platform to disseminate scientific evidence for low-carb, high-fat (LCHF, aka Banting).

LCHF is not yet mainstream. However, top specialists use it worldwide to enhance sports performance and treat obesity, diabetes, heart disease, cancer, even dementia. Some specialists now call dementia “type 3 diabetes” because of its link with diet. In medical jargon, these are called non-communicable diseases (NCDs). That’s a clumsy term for chronic ailments known as lifestyle diseases.

Noakes told the hearing NCDs at heart are diseases of nutrition. In particular, he says NCDs are diseases of insulin resistance.

This strange saga had its genesis in February 2014. That was when then president of the Association for Dietetics in SA (ADSA) Claire Julsing Strydom reported Noakes to the HPCSA for a single tweet to a breastfeeding mother. Noakes said that good first foods for infant weaning are LCHF – meat and veg. The problem for the HPCSA from the outset is that ADSA and Strydom give the same advice.

The HPCSA went ahead anyway and charged Noakes with unprofessional conduct for giving “unconventional advice”.

The HPCSA mustered a motley crew of expert witnesses to give evidence against Noakes at the November 2015 session of the hearing. These included North-West (formerly Potchefstroom) University nutrition professors Este Vorster and Salome Kruger, and paediatrician Dr Muhammed Ali Dhansay.

Noakes’ advocates, Michael van der Nest SC and Dr Ravin “Rocky” Ramdass, a medical doctor with 24 years experience as a family physician, had a field day in cross-examination. They eviscerated the evidence of all the expert witnesses, eliciting major concessions.

That included the HPCSA’s last hope at the February session: Stellenbosch University psychiatry professor Willie Pienaar. Pienaar has a masters degree in medical bioethics and lectures part-time in the subject.

He insisted that Noakes did have a doctor-patient relationship with the breastfeeding mother on Twitter. He said Noakes gave advice without knowing anything about the infant’s state of health.

Van der Nest said that if that were the case, then Strydom was just as guilty. So was another ADSA dietitian, Marlene Ellmer, who also gave information to the breastfeeding mother on Twitter. The HPCSA should have charged them both, said Van der Nest.

That is just one sign of an object lesson in unintended consequences on and off social media. And it isn’t only the HPCSA, ADSA and Strydom who are learning it. Top medical doctors, including thehead of bioethics at Wits University, Prof Amaboo “Ames” Dhai, and academics at UCT and other universities are learning it as well.

The February session opened with evidence of an email chain, which Van der Nest placed on the record. This suggested highly irregular conduct by the HPCSA Preliminary Committee of Inquiry that investigated the charge against Noakes.

Dhai chaired the committee. Members included UCT emeritus professor of surgery John Terblanche and retired UCT psychiatry professor Denise White.

Prof Amaboo ‘Ames’ Dhai

The email chain shows that Dhai and Terblanche went beyond their remit to ensure that Noakes was charged. They also appeared keen to see that the charge against Noakes would be successful. Noakes’ legal team say this could suggest that HPCSA has been biased against him from the start.

Van der Nest made another crucial point during cross-examination of Pienaar. It is one on which this hearing hinges: South Africa has a constitution that specifically guarantees scientists’ freedom of speech.

“This is important not only for our democracy,” Van der Nest said. “It is important for the development of humankind that scientists not be muzzled and that their freedom of speech is protected.”

The hearing has raised many questions. Among them is why the HPCSA and ADSA dietitians appear keen to limit Noakes’ right to freedom of expression.

Noakes is a medical doctor and one of few scientists in the world with an A1 rating by South Africa’s National Research Foundation. His rating is for both nutrition and sports science. He has three doctorates, one on medicine, one on sports science, and an honorary from the Vrye University, Amsterdam.

UCT deputy vice chancellor and law professor Danie Visser has called Noakes a “national treasure”, and “a force of nature”.

The hearing raises the question just why ADSA and the HPCSA don’t want South Africans to hear the scientific information Noakes disseminates. In answering those questions, the hearing throws up more usual suspects.

Prof Jacques Rossouw

A week before the February hearing began, the HPCSA said it would call Prof Jacques Rossouw as an expert witness. On opening day it announced it would not call him after all.

If the HPCSA intended Rossouw as a pre-emptive strike against Noakes, that was unlikely to happen.Rossouw may not have relished the prospect of debating the science on such a public platform.

South African-born Rossouw recently retired as head of the US National Institutes of Health (NIH) Women’s Health Institute (WHI) Branch in the Division of Cardiovascular Sciences at its National Heart, Lung, and Blood Institute. He is one of Noakes’ most implacable foes, and a staunch supporter of and researcher into high-carb, low-fat (HCLF) eating.

Presumably, Rossouw would have presented evidence from his WHI research and other research in support ofHCLF.

Noakes presented a vast body of science in his own defence. That was in more than 4000 pages and 900 slides with references from top scientists and institutions internationally, over nearly 40 hours.

Rossouw and the NIH have stayed mum other than to say that Rossouw couldn’t get permission in time from the NIH to attend.

Noakes says that there is no one study that conclusively proves him or any diet right or wrong . That’s because it is impossible to undertake such a study. (You’d have to lock around 50,000 people up in a hospital jail for 40 years. That would be difficult and costly, if not ethically suspect and physically challenging.)

He says there also compelling evidence that low-fat foods can over time cause heart disease.

“You have to look at the totality of the evidence,” Noakes said in his own evidence. “That’s what I am doing.”

Noakes calls himself “a totalist” who has”obsessive compulsive disorder with facts”. If anyone says that there’s no evidence to support low-carbohydrate diets, he says he tells them: “You haven’t read the literature.”

He told the hearing that LCHF was only unconventional to “those who refuse to look at the evidence.

He says tellshis students that “when a single strand of evidence conflicts with their beliefs, they better start questioning their views”.

Noakes has taken aim in his evidence at the diet-heart hypothesis that says saturated fat causes heart disease. It’s the one that started “lipophobia” (fear of fat), the demonisation of fat and glorification of carbohydrates way back in the late 1970s. It’s the one on which South Africa’s paediatric and adult dietary guidelines (which ADSA members drew up) are based.

Noakes presented evidence, including from Harvard in the US,to show that saturated fat doesn’t cause heart disease. He says that saturated fat is the victim of possibly the “biggest scam in the history of modern medicine”.

When food makers took saturated fat out of the diet, they had to replace it with something to make food more palatable, Noakes said. That something was sugar and carbohydrates that are highly addictive substances foods. The consequences for global public health have been nothing short of catastrophic: global NCD epidemics.

To balance Noakes’ contentions on diet, the HPCSA has tried taking a leaf out of the book of Noakes’ dream legal team, headed by Cape Town attorney Adam Pike, of Pike Law. It outsourced its legal team to Johannesburg lawyer, Katlego Mmuoe, of KK Mmuoe attorneys. It has also acquired its own doctor-turned- advocate Ajay Bhoopchand.

At the February hearing, Bhoopchand tried hard to stem the flow of science Noakes presented. He objected frequently saying that much of it, “while rather interesting”, was irrelevant.

Pretoria advocate Joan Adams. Picture: ROB TATE

Pretoria advocate Joan Adams, chair of the HPCSA Professional Conduct Committee that is hearing the charge against him, disagreed and overruled him.

The charge against Noakes might seem simple but it is complex, Adams said. It covers conventional versus unconventional advice and nutrition science; her committee unanimously decided there was no reason to limit Noakes’ right to defend himself fully and freely.

It has become clear that the hearing is a turf war: Noakes and LCHF on the one hand, and doctors, particularly cardiologists, ADSA dietitians, nutrition academics and high-carb, low-fat diets on the other.

Doctors and dietitians appear not to want Noakes giving advice that differs from the conventional medical HCLF “wisdom” they regularly prescribe; ADSA dietitians seem not to want him giving dietary advice at all. They see that as their turf.

But there’s another reason that some doctors, cardiologists in particular, may hate Noakes even more in future. He told the hearing that heart disease in future would be treated by hepatologists (liver specialists), not cardiologists.

Noakes presented compelling evidence in a study just two months old about the effects of non-alcoholic fatty liver disease (NAFLD). The study shows that NAFLD causes blood lipid (cholesterol) abnormalities that are linked to heart disease – so-called atherogenic dyslipidaemia – in people who are insulin resistant.

“We now know (heart disease) begins when the liver is full of fat,” Noakes said. “That is called a fatty liver. That’s non-alcoholic fatty liver disease.”

Noakes also presented the argument that diabetes is ultimately a disease of progressive, disseminated (widespread) arterial disease. He said it progresses over decades. It leads ultimately to complete obstruction of blood flow to the eyes, kidneys and lower limb blood vessels. The consequences are severe: blindness, kidney failure and gangrene of the limbs, the latter requiring amputation.

Heart attacks and strokes also occur as a result of this same progressive arterial disease, he said. However, they represent a “fundamentally different process”. Arteries that are incompletely obstructed develop an abrupt and complete obstruction as a result of rupture of the arterial plaque causing the arterial disease.

Scientists such as Rossouw claim that the falling rates of heart attacks indicate that the low-fat diet is working to prevent all arterial disease. Noakes offered a “quite different explanation”. He said that the reduction in smoking especially has reduced the number of patients experiencing the sudden plaque ruptures that cause heart attacks and strokes.

Fewer people are dying of heart attacks, but increasingly developing type 2 diabetes. That means that the disease burden of arterial disease has simply shifted to the obstructive form found in diabetes, Noakes said. If the low-fat diet really prevented arterial disease, as Rossouw and others claim, it should also have prevented the now much-more-prevalent obstructive form found in type 2 diabetics.

“I find it baffling why so many have difficulty understanding this obvious truth. Perhaps it is inconvenient?”